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House of Commons
Tuesday 14 March 1995
The House met at half-past Two o'clock
PRAYERS
[ Madam Speaker-- in the Chair ]
Oral Answers to Questions
HEALTH
Multiple Sclerosis
1. Sir David Madel: To ask the Secretary of State for Health what further research her Department will be conducting in 1995 into the possible causes of multiple sclerosis; and if she will make a statement.
The Parliamentary Under-Secretary of State for Health (Mr. John Bowis): My right hon. Friend the Secretary of State has written to you, Madam Speaker, and to the right hon. Member for Derby, South (Mrs. Beckett), to explain that today she is leading a trade mission to Japan and Korea to boost British medical exports and to bring inward investment and jobs to Britain.
To my hon. Friend the Member for Bedfordshire, South-West (Sir D. Madel), I reply that such research is mainly commissioned by the Medical Research Council and is the responsibilty of my right hon. Friend the Chancellor of the Duchy of Lancaster. The Department of Health does, however, have a programme of research which includes work on service delivery for people with multiple sclerosis.
Sir David Madel: In view of successful trials in the United States and completion of trials in the United Kingdom, will the drug beta interferon be available for multiple sclerosis sufferers on the national health service in the autumn and will trials on the drug rolipram begin in Britain this year?
Mr. Bowis: As my hon. Friend knows, the cause of multiple sclerosis is not known, so as yet there is no cure. The research and clinical trials to which he refers have been on drugs to alleviate symptoms of the disease. Beta interferon, as a biotechnology product, now comes under the European Medicines Evaluation Agency and I cannot say whether, when or in what form a licence will be granted by it. The Medicines Control Agency in Britain has not yet approved any clinical trials on rolipram because no such proposals have yet been put to it.
GP Fundholders
2. Mr. MacShane: To ask the Secretary of State for Health what restrictions apply to GP fundholders in respect of using public money to improve their property portfolio.
The Minister for Health (Mr. Gerald Malone): General practitioner fundholders may, with the agreement
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of their regional health authority, use audited savings for the benefit of their patients. This includes improving their surgeries to provide a wide range of services.Mr. MacShane: Is there not growing concern among medical practitioners that some--not all--fundholders are not treating a required number of patients in order to improve the value of their property so that at the end of their practice they can sell it and make a large personal profit? If a doctor approaching retirement has a choice between 10 hip operations or adding £100,000 to the value of his property, that is a choice introduced by the Government to allow fundholding doctors to turn themselves into small businesses and put profit before patients.
Mr. Malone: I hope that every general practitioner fundholder across the land will have heard what the hon. Gentleman has said, which is a slur on most of them, on those whom he was mentioning, and noted his tendentious use of the words "property portfolio" in his question when what he should have said was surgery premises. It is not unusual for public funds to be made available for the improvement of premises. That was always the case when grants were made available before to improve the capital asset with precisely the same effect as if GP fundholders use their savings now. I just wish that the hon. Gentleman would bear in mind the additional services that are being provided for patients--the improvements, the physiotherapy and the capital equipment that is brought into the premises. Fundholding is a great success and it does doctors no good when the hon. Gentleman denigrates them in that way.
Mr. Patrick Thompson: Bearing in mind the fact that more and more GP practices are opting for fundholding with clear benefits to patients throughout the country, is my hon. Friend aware that the Opposition are now in as much of a muddle about the future of health care as they are on education? Will he give some help to the right hon. Member for Derby, South (Mrs. Beckett) to sort that out?
Mr. Malone: Not only am I keen to help the right hon. Lady; I have already done so. I wrote to her yesterday asking whether she might now be prepared to clarify her party's position on this important point. Perhaps she will have an opportunity to say whether she agrees with the Leader of the Opposition, and reveal that yet another layer of veneer is to be added to left-wing policies.
Residential Care
3. Mr. Denham: To ask the Secretary of State for Health what steps she intends to take to improve residential care for the elderly.
Mr. Bowis: Our inspection regime ensures that local authority-run homes are inspected against the same standards as are expected of independent sector homes, and we have now applied citizens charter principles to both. Standards also of course benefit from the statutory direction on choice, which gives residents the right to choose their home.
Mr. Denham: Is the Minister aware of the anger and fear felt by elderly people whose homes, life savings and partners' pensions are confiscated to pay for residential care? Is he aware that, as the Southern Daily Echo has pointed out, those who can plan ahead and pay legal fees
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can avoid high charges, while others cannot? Is it not clear that residential care is now a national lottery in which frail elderly people are losing control of the type, quality and cost of the care that they need?Mr. Bowis: What is certainly clear is that such comments do nothing but undermine elderly people's confidence in the excellent care provided by residential care and nursing homes throughout the country--and, indeed, by social services departments and health authorities working together.
If the hon. Gentleman knows anything about the matter, he will know that there have been no changes in the principles of charging for social care since the founding of the welfare state in 1948. What was good enough for Beveridge and Aneurin Bevan--and, more recently, for Sir Gordon Borrie in the Labour party's own Commission on Social Justice--should be good enough for the hon. Gentleman: while of course people must look to the costs of their own social care, their health care will continue to be free at the point of delivery. That includes residential care.
No one, but no one, risks the eviction of his or her spouse from the home because of charging policy, as some have suggested. That is specifically excluded, as is the eviction of any dependent relative, and the spouse's normal standard of living will also be taken into account.
Mr. Rowe: Is my hon. Friend aware of the admirable plan of Kent's director of social services to involve local communities much more closely in residential homes? Does he agree that such a clear use of the voluntary spirit should be encouraged, and will he do his utmost to encourage those admirable ideas?
Mr. Bowis: Yes. We should involve all the relevant agencies in the planning of social care, including social services departments, health authorities, GPs and the voluntary sector--and, of course, users and carers themeselves. My hon. Friend is right to point out that volunteers can play an important part in the provision of services: they can back up the statutory agencies, and many can gain great benefits themselves from supporting others.
Mr. Hinchliffe: Given that the Government have cut 50,000 local authority care home beds, and the Department of the Environment's current proposal to remove the statutory requirement for local councils to provide their own care homes, will the Minister explain how his concept of choice applies to elderly people who choose to enter local authority care homes?
Mr. Bowis: Would that some of the local authorities that are run by the hon. Gentleman's party gave individual residents and potential residents real choice. Real choice is informed choice, not just the choice between two local authority homes.
If a local authority believes, as many do, that it can secure better quality at a better price from the independent sector, that will be good for residents and taxpayers. I should have thought that the hon. Gentleman would have the grace to welcome it.
Dame Elaine Kellett-Bowman: Is my hon. Friend aware that Lancashire has many excellent county and privately run residential homes? Is he further aware that it costs £93 a week or, in total, £10.8 million more to
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keep people in county-run rather than private sector homes? Should that matter not be looked into so that that £10.8 million could be spent in other ways?Mr. Bowis: My hon. Friend is right. As I go around the country and see the excellent provision by the independent sector, which is scorned and spurned by some local authorities for ideological reasons, I consider the cost of that provision and I notice, as my hon. Friend says, the savings that could be made. That could provide better quality and, very often, better comfort for individuals, and leave more money to be spent on people in need. Where hon. Members see such a waste of money, I hope that they will unfailingly send the details of it to the district auditor so that it can be considered in his assessment of value for money in local government.
GP Fundholders
4. Mr. Milburn: To ask the Secretary of State for Health if she will make a statement about GP fundholders' savings.
Mr. Malone: Fundholders have achieved efficiency savings of nearly £110 million over the first three years of the scheme. That is about 3.5 to 4 per cent. of budgets set. That money is being reinvested in health services for the benefit of patients. In the hon. Gentleman's constituency, for example, it has been reinvested in physiotherapy services, the purchase of electro-cardiogram equipment machines, more space for doctors to practise and additional nursing cover. I am sure that he will welcome all that.
Mr. Milburn: Why should a minority of family doctors be allowed to sit on what amounts to a huge public subsidy when more than 1 million people are waiting for hospital treatment? What action is the Minister prepared to take to ensure that public resources are made available now for all members of the public, or is he content merely to see the further development of a two-tier NHS?
Mr. Malone: The hon. Gentleman's expertise in these matters seems to extend no further than Essex, where he finds woks for sale in GP fundholders' premises. I am glad that he has treated the House to something slightly more serious than that. As he knows, those savings are spent on a rolling basis. Plans are not only agreed with the regional health authority but audited on an on-going basis. The money is spent on a year-on-year basis on patient care. I should have thought that, because much of that has happened in his constituency, he might have welcomed it.
Mrs. Roe: Does my hon. Friend agree that the ability to make savings that can then be spent on more and better patient care is one of the main benefits that GP fundholding has been shown to have? Does he further agree that one of the places where that message has been heard loudest and clearest is the region represented by the right hon. Member for Derby, South (Mrs. Beckett), where nearly three quarters of the population have a GP fundholder--twice the national average?
Mr. Malone: My hon. Friend is quite right. I had the pleasure of visiting the regional health authority that covers that area. It explained how enthusiastic GP fundholders in the right hon. Lady's constituency were in taking up the challenge that the policy offers, and in
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bringing benefits to their patients. They will understand that it is a policy that, at least until yesterday, we understood that the Opposition were going to abolish.Mr. Alex Carlile: Does the Minister agree that any benefits available to the patients of GP fundholders should be at least equally available to patients of non-fundholders who join joint commissioning arrangements, such as those that exist in Nottingham? Will he commend joint commissioning arrangements? If any savings are achieved from fundholding, will he consider applying them to the nearly 900,000 people who have been struck off dentists' NHS lists since the previous general election?
Mr. Malone: The hon. and learned Gentleman raises an interesting point about people who will not join GP fundholding practices, but who provide the benefits by other means. Of course, GP fundholding is voluntary. That is the preferred way of moving forward in a primary care- led NHS. That will continue to be the case, but, if others choose another means and manage to learn from the best practice that has been made available by GP fundholders, I welcome that.
Administrative Posts
5. Mr. Harry Greenway: To ask the Secretary of State for Health which administrative posts in the NHS are normally filled by nurses, doctors or other medically qualified persons; which are normally filled by people with other than medical qualifications; and if she will make a statement.
The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville): All NHS trust boards must have a qualified medical director and a suitably qualified nurse as director of nursing. Otherwise, it is a matter for individual NHS bodies to decide what skills, expertise and experience are required.
Mr. Greenway: Does my hon. Friend agree that medical people are best placed to understand the medical needs of hospitals and other facilities in the NHS? Will he make it a priority to appoint them to administrative posts, where their medical experience can be used, and please can we have the matron back in hospitals?
Mr. Sackville: On the last point, many of my hon. Friends used to show a marked predilection for a strong woman in charge. I have no objection to the person in charge of nursing, or of any other responsibilities, being styled as matron or, indeed, patron.
Mrs. Beckett: Does the Under-Secretary recognise that not only has the number of those described as general and senior managers quadrupled since the Government's changes were introduced but the pay bill for those posts has trebled? Has the Under-Secretary seen the recent figures produced by the National Health Service Consultants Association, which show that, overall, the administrative costs of the health service are twice what they were before the Government introduced their so-called reforms? At a time when we are constantly being told that there is not enough money to provide essential care, does that not show how the Government waste public money?
Mr. Sackville: I remind the right hon. Lady that a large proportion of the additional managers have been reclassified from their previous posts and the hon.
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Member for Newcastle upon Tyne, East (Mr. Brown) has admitted as much. I remind her also that half all managers come from a clinical background. If the right hon. Lady is worried about this, she should look to see that activity in hospitals has increased enormously. Outcomes have improved and waiting lists are down as a result of good management of hospitals. Hospitals do not manage themselves; they need good, committed managers.Mr. Lord: My hon. Friend's response to the question from my hon. Friend the Member for Ealing, North (Mr. Greenway) was tinged with a certain amount of humour, which is always the case when matron's name is raised in the House. Does my hon. Friend agree that the matron was probably the most important and effective post in hospitals throughout their history? It was a sad day when the post of matron was abandoned. If the Minister wants to do something that will have a major effect on the way our hospitals are run, he could go back to his office this afternoon and write a letter to every hospital in the country, recommending that they reintroduce the post of matron without delay. Will he consider doing that?
Mr. Sackville: Every hospital has the opportunity to recreate the post of matron, and some are doing so.
Specialist Appointments
7. Mr. Lewis: To ask the Secretary of State for Health what measures she proposes to ensure early specialist appointments following GP referrals.
Mr. Sackville: For the first time, we have introduced a national waiting time standard for out-patient appointments.
Mr. Lewis: After that unsatisfactory reply, will the Under-Secretary consider the effect of the 18-month demand on consultants which is required by the patients charter? Will he look at Withington hospital in south Manchester, where consultants are now writing to GPs saying that, because of that demand, they cannot accept further referrals? That is another hidden waiting list and it is time that the Minister got off his fat backside and started to tackle the problem properly.
Mr. Sackville: The history of waiting lists and waiting times has been a major success of the NHS reforms. All the unacceptably long waits have been removed. Guarantees are being offered for out-patient appointments as well as for in-patients and for those waiting for operations, and the average waiting time has come down from nine to five months. That is a very real achievement.
Mr. Garnier: Is my hon. Friend aware of the re-engineering project that has been carried out at Leicester Royal infirmary, which has enabled out-patients to see specialists and technicians at one place and during one appointment so that GPs receive the answers to their referrals within hours rather than weeks, which was previously the case? Is that not an example that should be followed by other NHS trusts and hospitals?
Mr. Sackville: Yes, I congratulate Leicestershire on its achievement. We hope to encourage exactly that sort of initiative everywhere.
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Mental Health Care
8. Mr. Flynn: To ask the Secretary of State for Health what new proposals she has to improve mental health care.
Mr. Bowis: A large range of measures for in-patient and community services is being implemented, and our new Mental Health Bill is being considered in another place.
Mr. Flynn: Does the Minister agree that not only are mixed-sex wards unacceptable and distressing to patients, but so are wards which have an unacceptable range of mental ill health? A 22-year-old young woman constituent of mine, who had suffered a nervous breakdown, found herself sharing a ward with people who were deeply psychotic and she was assaulted twice by a young male patient. Is it not utterly unacceptable that our mental hospitals, as a result of the Government's changes, have been turned into places which increase anxiety and stress to staff and patients?
Mr. Bowis: The hon. Gentleman refers to a hospital which is in his constituency in Wales and, therefore, is a matter for my right hon. Friend the Secretary of State for Wales. I understand that Welsh questions were yesterday. I shall, however, answer in the general sense, since the matter applies to English health questions as well. It is appropriate that every health authority in the country should look at its range of provision and ensure that it meets what it assesses locally as being its need. That is what we have been encouraging them to do and that is what they are doing. We are looking for the right mix of acute beds, long-term beds, medium-term beds, low, medium and high-secure beds and a range of facilities in the community. They are being provided in most parts of the country and we are determined that they will be provided in all parts of the country.
Mr. Sims: My hon. Friend will recall that about 12 months ago, the Select Committee on Health issued a report on these matters, in which it criticised the Government for the delay in implementing the homeless mentally ill initiative and for the lack of co-operation between his Department and the Department of the Environment. Will he assure me that those problems have been addressed and that the provision of housing for the mentally ill under that initiative is proceeding?
Mr. Bowis: Yes. I thank my hon. Friend for his question. He will also recall that the homeless mentally ill initiative has been a remarkable success story, not least because of the outreach teams which have been reaching increasing numbers of homeless mentally ill people. The initiative has also been a tremendous success in providing accommodation, the first stage of which has been hostel accommodation. I have opened a number of hostels around London and I am due to open another one shortly.
My hon. Friend is also right to point to the need for a good system of agreed move-on accommodation. In the past, lack of that has caused delays. That is why we have been working closely with our colleagues in the Department of the Environment and why we have also
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been working closely with the inner London boroughs especially. I am pleased to say that some helpful progress has been made by those boroughs for future provision.Mr. Illsley: Is it not the case that the Government are bringing forward controversial, unpopular and piecemeal initiatives on mental health rather than addressing the real issues such as the diversion of resources away from mental health into other parts of the national health service, the closure of long-stay institutions, the lack of a comprehensive strategy for mental health and the relationship between mental health and homelessness, unemployment and sexual and racial discrimination? Is it not time that the Government addressed the whole matter of mental health and perhaps committed themselves to a complete review of the Mental Health Act 1983?
Mr. Bowis: I do not know where the hon. Gentleman has been. One of the five key parts of "The Health of the Nation" strategy is mental illness. We have been working hard with all the agencies involved to improve the standing of people with mental health problems. He will also know that we have been implementing our 10-point plan over the past 18 months, which has ranged from supervision registers and hospital discharge guidance through the training of key workers to supervised discharge, which is in the Mental Health Bill that is before Parliament.
Resources to the tune of £2.3 billion have been put into mental health this year. Through social services, we have been putting money into local government provision to the tune of some £180 million and our mental illness specific grant has supported 1,000 schemes and 100,000 people. The missing link to which the Blom-Cooper and other reports have referred was partly supervised discharge and partly medium-secure beds. Those were missing because, during the previous Labour Government, not a single bed was provided, whereas we shall be providing some 1,300 beds by 1996.
Health Authorities Bill
9. Mr. Thomason: To ask the Secretary of State for Health what assessment has been made by her Department of the likely savings to be made for the health services as a result of the Health Authorities Bill; and what savings will be made.
12. Mr. David Martin: To ask the Secretary of State for Health what estimates have been made of the savings resulting from the abolition of the regional health authorities.
Mr. Malone: The provisions of the Health Authorities Bill, which will abolish regional health authorities and require district health authorities and family health services authorities to merge, will result in annual savings approaching £150 million by 1997-98. Some £100 million of the total savings will result from the abolition of the RHAs and the consequent reduction in the overlap of work between the national health service executive and the regions. All those savings will be retained by the NHS and reinvested in patient care.
Mr. Thomason: I welcome that answer. Can my hon. Friend confirm that the changes will mean that there will be more money available for patient care, whereas Labour's proposals to create strategic health planning would take money away? Does my hon. Friend agree that
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this is another case in which the right hon. Member for Sedgefield (Mr. Blair) should tell the right hon. Member for Derby, South (Mrs. Beckett) that she has got it wrong again?Mr. Malone: I would never presume to tell the right hon. Member for Sedgefield what messages he should give to the right hon. Member for Derby, South. All I notice occasionally is that, when he gives them, she does not pay a blind bit of notice to them; but never mind that. The position set out by my hon. Friend is absolutely right. Of course those funds will be available for patient care. I noted, when the Health Authorities Bill was in Committee, that the Labour party wanted to reimpose bureaucracy and to take the money that would be available for patients away.
Mr. Martin: Can my hon. Friend confirm that the welcome abolition of Wessex regional health authority is part of a general and consistent assault on bureaucracy throughout the national health service, not least in hospitals themselves? Can he confirm that the savings created from this will go not only to patient care, but to ensuring that consultants working in hospitals can get on with treating patients rather than worrying about paperwork?
Mr. Malone: My hon. Friend is right. The Government have a consistent record of cutting bureaucracy not only in administering the NHS and the country, but within the Department of Health, in Whitehall and in the NHS executive. Constantly paring away bureaucracy means that funds are released for patient care. That is a proud record, which the Labour party tries to interfere with and upset.
Mr. Barry Jones: How many additional nurses will result from the savings?
Mr. Malone: The sum of £100 million a year is substantial. When it is redirected into the purchasing process, it will allow a substantial increase in activity. That figure would represent something approaching-- this is a top-of-my-head calculation at the Dispatch Box to which I am sure the hon. Gentleman will not hold me--20,000 cardiac bypass operations. The hon. Gentleman wants to put the figure in the scale of things and to know what it will mean for patients; that is a pretty good try.
Mr. Nicholas Brown: This is a refinement of the way in which the Minister answered the question in Committee. As he says that there is extra money to invest in the national health service, will he now explain to the House what the Prime Minister meant last Thursday when he said that there was available in Leeds
"a highly specialised form of treatment"?--[ Official Report , 9 March 1995; Vol. 256, c. 454.]
By implication, such treatment was not available in Greater London. Is such a facility to be made available in Greater London? What exactly is available in Leeds and not available in Greater London?
Mr. Malone: The hon. Gentleman will know that he is distorting my right hon. Friend's words in a ridiculous way. First-class health services are available across the country, not least because the Government have put into place policies that mean that more money is directed straight to patient care than is absorbed by the rest of the
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service. That is why first-class services are available across the land. It is wrong of the hon. Gentleman to treat my right hon. Friend's remark in that way.Human Embryos
10. Mr. Alton: To ask the Secretary of State for Health what discussions she has had with the Human Fertilisation and Embryology Authority about the freezing of human embryos.
Mr. Sackville: Officials of the Human Fertilisation and Embryology Authority are in close contact with those of my Department on the matter. When the authority has reported and submitted its review of current arrangements we shall consider whether further action is appropriate.
Mr. Alton: In how many cases has contact been lost with the parents of the 30,000 human embryos that have been frozen in the past decade? Will an amendment to the law to prevent those embryos from being destroyed when their shelf-life expires next year be among the proposed courses of action that the Minister has said will be considered? What account is being taken of the evidence published in The Lancet in the past month or so showing that the freezing of mouse embryos has led to mutations occurring in the mice subsequently born?
Mr. Sackville: Clearly there will be many such cases, but the hon. Gentleman must remember that Parliament decided that treatment involving the implantation of embryos should go ahead, and that a feature of such treatment is storage.
Mr. Sackville: Parliament agreed a maximum period of five years for the storage of embryos. That raises many sensitive issues, which is why the authority is now considering the matter.
Madam Speaker: If the hon. Member for Carrick, Cumnock and Doon Valley (Mr. Foulkes) did not talk so much he might be able to hear the Minister.
Dr. Spink: Has my hon. Friend had time yet to review the accounts of the Human Fertilisation and Embryology Authority that were published yesterday? If so, did he note that it will receive about 70 per cent. of its income next year from licence fees? Does he not think that that puts the gamekeeper a little too close to the poacher? Is there not an inconsistency here? Can he tell me how many licences have been revoked or withheld in the past year?
Mr. Sackville: My hon. Friend's use of the word "poacher" is inappropriate, if I may say so. I have the highest regard for the people who work for the authority and for the way in which they carry out a very sensitive job. I believe that we are respected throughout the world for having set up an authority to regulate this difficult area, and I know of no reason for any suspicion of a conflict of interests of the sort that my hon. Friend alleges.
GP Fundholding
11. Lady Olga Maitland: To ask the Secretary of State for Health what plans she has to extend general practitioner fundholding; and if she will make a statement.
Mr. Malone: In October 1994 we announced a major extension of the options for general practitioner
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fundholding, the development of a community option and the expansion of standard fundholding. In addition we continue to look at other services and other ways to develop the benefits that can be achieved through fundholding. Our aim is to extend the benefits for patients as widely as possible.Lady Olga Maitland: Is my hon. Friend aware that although 30 per cent. of my constituents enjoy the excellent services of GP fundholders, none the less that percentage is below the national average? What steps will he take to ensure that my constituents in Sutton and Cheam enjoy the same benefits as other people who are patients of GP fundholders?
Mr. Malone: I am sure that my hon. Friend will take her own steps, as she regularly does, to ensure that all general practitioners in her constituency are aware that fundholding status is available to them. Under the new scheme, about 85 per cent. of GPs are now eligible for fundholding status, and we fully expect the percentage of the population covered to increase dramatically over the next year or so. We are seeing progress to that end, and we expect that progress to be maintained.
Mr. Austin-Walker: Before extending GP fundholding, will the Minister look back at the answers to the questions that I have asked about it? He replied that he did not hold the information centrally and referred me to the regional health authority and the family health services authority. Is he aware that the regional health authority has given me two different figures covering the constituency of the hon. Member for Sutton and Cheam (Lady Olga Maitland), which in terms of underspending are more than £100,000 apart? For Camden and Islington, the figure given by the regional health authority is almost twice that given by the FHSA. Does the Minister agree that until he can get his house in order, monitor the figures and find out what is happening to the underspend, he should not extend the practice further?
Mr. Malone: Again, the hon. Gentleman is simply trying to deny the fact that fundholding brings additional benefits for patients, and I am surprised that Opposition Members have not caught up with the news.
Mr. Malone: The hon. Member had better not say that to the Leader of the Opposition, as the Labour party has now changed its policy on the subject.
The figures taken over time from family health services authorities and the regions will give different snapshots, but they will be consistent once they have worked through the system. I reiterate that funds that are made available for patient care according to plans approved by the region and by fundholding practices have been passed by the Audit Commission. I could not suggest anything to the hon. Gentleman that could be more stringent than that. It is a quite proper use of public funds for patient care.
Mr. Anthony Coombs: As more than 90 per cent. of my constituents will soon be enjoying the benefits of being treated by GP fundholders, does my hon. Friend agree that they will find the remarks of Opposition Members- -particularly the hon. Member for Rotherham (Mr. MacShane)--deeply offensive? Does he agree that total fundholding as practised originally in Bromsgrove and now being extended to Bewdley in my constituency
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is a way forward to make GP fundholders the real gatekeeper of health services and to ensure that those services reach ever-higher standards for patients?
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